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What A Chief Nursing Officer Learned By Going Undercover

April 24, 2024

What A Chief Nursing Officer Learned By Going Undercover

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April 24, 2024

What A Chief Nursing Officer Learned By Going Undercover

April 24, 2024

Erica (00:00):

Welcome everyone to today's webinar, What a Chief Nursing Officer Learned by Going Undercover. On behalf of Becker's Healthcare, I'm Erica Carbajal and thank you all so much for joining us. We also want to thank works the healthcare industry's leading flexible workforce platform for bringing us together for this conversation today. Before we start off, I've got a few just quick backend notes to walk through so you can go ahead and submit any questions you see throughout the webinar by typing them into the q and a box. You should see on the right side of your screen the session is also being recorded so it will be available after the event. If you want to go back and reference any of the information, you will be able to do so using the same login information you use to log in today to access that recording once it's available. And if at any time you're having any technology issues or trouble with audio, please just try refreshing your browser and you can also type in any technical questions into the q and a box and we're here to help on the backend with those. With that, we're so thrilled to welcome today's speakers. First we have Brian Wyrick, chief nursing leader of Banner Health and Rose Sherman, professor emeritus at Florida Atlantic University and editor in chief of nurse leader Brian and Rose. Thanks so much.

Rose (01:19):

Thanks for having us.

Brian (01:21):

Yeah, thank you.

Erica (01:23):

Well, Brian, I know in between executive positions you decided to take a 13 week travel assignment on a medical surgical unit outside your health system and know what you learned, surprised you change your perspective and will inform your work in the future. So I know you and Rose are going to get to talking about that, but before we get started here, Brian, if you could just speak to help us understand what prompted you to take a clinic day one a step further and commit to that MedSurg travel assignment.

Brian (01:54):

Yeah, thank you Erica. This was a decision I thought about for a long time and it was not intentional to lead to where we are now, but I had been a chief nursing officer or CNO I guess going on seven years at two different health systems. And I've always seen myself as a player's coach, a very visible leader, rounding frequently, all shifts, even doing an initiative we did called Moments of Gratitude, which would be like four hour blocks on a unit really diving in, helping pull linens, empty trash, clean break rooms, more than just executive leader rounding. I always got a really good ROI for that. It was in 2022 that I was promoted into a system nursing role. This was a corporate role. Banner's a very large health system, so I had an office at corporate, but this was the tail end of the pandemic.

(02:50):

We were largely remote at the time and I was really nervous about losing that connection to the bedside staff, the daily operations. I think of myself as a very strategic thinker. I was excited about the opportunity to focus on emerging technologies, new models of care, but I needed to stay clinically relevant. And also when you're focusing on new technologies and new models of care, I wanted to test my assumptions. The worst thing you can do is create tools to solve problems that aren't really problems or that team members don't need. I thought about taking a PRN job, but you have to orient on day shift and go through that. And really the path of least resistance was to be a traveler that you could start minimal orientation. And I thought, okay, I'm going to do this route. I don't know that I ever intended to finish a 13 week assignment.

(03:41):

I'm an ICU nurse by background. I didn't think I could go into an ICU. I have kept my BLS and ACLS up, but I'm so far removed from the bedside. I thought, hey, an ICU might not be safe. My ego told me I can go to med-surg, the basic skills will come back to me. I've got really good time management, I should be able to go there and cruise. So that's how I chose a med-surg assignment and I chose a competitor in town. I didn't know if I could do this to be honest with you. And if I decided to do shifts at my hospital and take five and six patient workload, what if I couldn't do it? What if I had an adverse event or a med error or what if I just couldn't keep up with the work and then left? What message would that send to the staff? So I decided to do it at a competitor in case I couldn't finish or anything like that. That wasn't the case and I learned a ton through the process.

Erica (04:39):

Yeah, fascinating to hear about all that background and I think such a timely session and discussion, especially as we hear about continue retention, turnover rates in med-surg units. So what a way to get a real feel for what's really happening. Rose and Brian, I'll go ahead and turn it over to you now to share more.

Rose (04:58):

Well, thank you Erica and Brian, really excited to talk with you about this because when we originally published this blog, you were incognito. I probably had tons of people ask me, who wrote that? Who was that about? And at that point in time I couldn't tell them. So what has led you to talk about this experience more publicly now?

Brian (05:24):

Yeah, initially I was incognito and we'll use that term because I was working at a competitive health system in town. I did not want them, my coworkers to know who I was because I didn't want to answer those questions and I didn't want to be treated any differently. I didn't want the questions to come, Hey Brian, what are the nursing pay rates at this hospital? What incentives are you using? Are you lowering traveler rates? What's your staffing ratio? I didn't want to answer any of those questions and I wasn't there to recruit nurses to recruit staff. This was truly for me to learn, connect dots, learn the electronic health record, test my assumptions and get a really good understanding of what the team members are going through. This was the back end of the pandemic. During it, a couple weeks in, I reached out to you Rose, I think of you as a true mentor and leader.

(06:19):

And I said, Hey, you're not going to believe what I'm doing and more importantly, you are not going to believe what I'm learning. And I was like four or five weeks in. So at the time I didn't want to put my name out there. I was still in the assignment. I didn't want to answer those questions, but when the assignment was over, I very, I reflected a lot on this, I learned a lot. My wife is also a nurse, so we talked about this and then I started talking about it publicly right away, getting in front of nursing students and nurses who are new nurses who are onboarding. I always get a good reception when I shared this story and really for one, I wouldn't ask you to do anything I wouldn't do as a nurse leader, but I would go and do take these assignments, right ups and downs for sure. But that's really, and then as it has continued to evolve and more people know, I did my travel assignment through Trusted Health was the agency I used and I told them who I was afterwards and they were very receptive of this and said, Hey, you need to tell more people. And they're the ones who kind of set this up today. As I said, I am telling people, I'm like, you're not telling enough people about this. So looking forward to the next hour with you.

Rose (07:28):

Yeah. Well I think a lot of, one of the responses that I got right away, Brian, was that was really gutsy to put himself in that position. And I think you've talked a little bit about why you did it. I guess I'm wondering what surprised you the most about taking this travel assignment? What are some of the unanticipated things that you did not expect?

Brian (07:55):

Well, I really wanted to focus on, again, testing my assumptions, new models of care, emerging technology, natural language processing, this AI ML takeover that we're in, do these work. That's what I really wanted to do. One of the things I learned the most though is a lot of our nurses are not having their basic needs met. And before you can build these levels of complex technologies without having that strong foundation, it's just not going to be successful. So those basic needs have to be met initially. That was one of my key takeaways at the conclusion of this.

Rose (08:33):

Well, I think in the blog you mentioned that you felt that there was a need for more positive recognition, and I think what really stood out to me was that you said as you looked at the communication that was coming in from the executive team in the medical center and you looked at it through the eyes of the staff as they were looking at it, you really felt like much of it seemed very punitive or negative. Can you talk more about that?

Brian (09:05):

Yeah. One of the things, and I was looking at this through a unique lens, one of the things where if the unit has a quality board, it has to be kept up to date by leadership. If it's not, it sends a very clear message of what is and isn't important. So if you've got data that's two months old, if you're monitoring falls or any hospital acquired infection, that really sends a strong message to the team. During my assignment, I had two positive feedbacks that really made me feel really, really good. And I was surprised at how I reacted to this one. About halfway through, I was asked if I would take externs. This health system had a really good extern program. These were students in their last year of nursing school. They could work as a patient care tech, but they could do more skills.

(09:55):

And it made me feel really good to be asked to take externs as a travel nurse. And then they asked me to take students and I thought, again, wow, that's the biggest compliment you could give me, asking me a traveler to do this. And I felt very good about that, getting that recognition, but I didn't need recognition. I've been a nurse for 18 years. I could have quit this travel assignment any day, but there was a lot of new graduates on the unit. I thought, if I'm feeling this good for positive recognition, they need this a hundred times what I'm getting because it's a tough environment. And as I'm looking at the communication that was coming out, a lot of it, I don't want to say punitive, but it was you collectively, this policy is changing or here's a reminder of this policy. We had a lot of continuous bladder irrigations on the unit, the five bags, you put it way outside the room, a lot of empty bags. And we got a lot of communication about people doing this wrong. And it really felt like we were just trying to live 12 hours at a time and provide good care to these patients. And this particular unit had a very heavy workload, six and seven patient ratios with multiple patients on continuous bladder irrigation that it made you run, it made you work really hard. And the communication was constantly, this is the policy, it's not being followed, do this or else. And that resonated with me.

Rose (11:26):

Well, just as a follow up to that, Brian, I think one of the things that a lot of executive leaders struggle with right now is just communication, how to communicate to staff what methods of communication are the most effective. Have you changed your communication at all as an impact of having done this

Brian (11:45):

Afterwards? And I guess kind of simultaneously, email's not the way to go. It does lead to paper trail, but I liked using live video updates with a selfie stick or with an iPhone on a stand, but doing a video update and then uploading those to a platform, whether it's like a private Facebook group or Yammer. And then through those you can monitor how many people have watched this. But you can get, if something changes today, I could get that out to a large group in an hour and it's my face, it's me talking. It's not an email that's buried in their inbox. That's probably the one big change I did during this time.

Rose (12:26):

Yeah, that was probably a great learning because many staff, they just don't have time to read all this communication and they are in cognitive overload, as you said in the blog, you were as well. And so one of the things that I hear managers and leaders talk about today, Brian, is that staff seem very transactional when they make these requests, when they're requested to work overtime or they themselves want scheduling changes that it all seems so transactional to the leaders. How did this experience maybe change your thinking about these exchanges that go on between leaders and staff asking one another to do things?

Brian (13:16):

This was one of my big aha moments because I've been in the C and o chair so many times when we're going into the weekend or to the end of the week and we're looking maybe a shift ahead, we're looking at night shift or tomorrow day shift and we're significantly short staffed. We're not going to be able to have appropriate and efficient daily operations. So here's where the pay incentives come out right now. What are the carrots we can dangle to get staff to come in? And as a CNO, it always felt like everybody's holding out until we give a bigger, we offer a bigger carrot and then we'll get people to sign up and Hey, we're trying to deliver patient care here. Why would you guys hold us hostage? And I get the dollar conversation and so forth. But that was always my perception until I lived it on the other side.

(14:12):

So this was maybe a Friday night at 8:00 PM I'm coming on to shift, I work night shift. Day shift is leaving and the day shift charge nurse says to the collective, Hey, we've got a lot of patients in the emergency department. We're going to fill up tonight and tomorrow morning we are going to be significantly short just with the volumes we already have. And if we have any call offs, we're going to be in trouble. Is anybody willing to pick up tomorrow? And I'm watching this play out in the immediate question is what incentives are being offered? And at this health system, they had a standard stipend per shift. I think it was like hundred dollars and they could use callback pay. And then they had double time. And it was very clear the nurses wanted double time. That was the desired incentive for them to work.

(15:03):

And the charge nurse said, no, this has been escalated to the house supervisor and the CNO and the responses we're not offering double. And the conversation among these nurses that I was watching, they all had a good reason. One of 'em said, it's eight o'clock at night, I would have to find childcare for essentially 13 hours tomorrow. And then to pay for childcare for 13 hours isn't worth coming in for that hourly rate. I would lose money and I lose an entire day with my infant. I was like, wow, that's a really good point. And then another one said, I just bought my daughter her first car. I have worked so many shifts, I just need a day off. I'm not going to work. There's no amount of money it's going to bring me in. I had met this goal and then another one said to those other two, if they do offer double bonus, don't put it on our group text because Mike, who I presume was her husband, will make me come in and I need a day off.

(16:03):

And I thought her and Mike probably have some financial goals, you know what I mean? And he's saying, go take advantage. And she's saying, I need a break. But none of the three of them were out to stick it to management. They had very real life instances that they were weighing to decide if they wanted to come in or not. And I watched that and they were all very sincere in their declining of picking up this shift. And it was all family related and very, very good reasons. And I had never seen that. And the c and o, whenever he or she got the report, nobody's picking up. I know the reaction they're going to have because they got to solve this, but it's not because they were out to get 'em.

Rose (16:46):

So just as a follow up to that, Brian, is there a better approach that A CNO could use other than what was used in that circumstance and maybe what you yourself have used in the past?

Brian (16:59):

Yeah, I think there are technologies coming out. I would lean on technology. You have to take the negotiation out of it for management and staff, I really go to think about the gig economy and a higher PRN pool. You have to have more nurses to tap into and you have to automate that. You can't have managers in their offices texting, blast texting all day in morning. And then in the afternoon when there's a new new incentive that's offered, bring in a platform or an application that leadership can put guardrails or triggers in that automates all of that, the communication, the incentives and let that work for you. That's what this new technology with machine learning is incredible. That's what makes me think we have to tap into that. Just begging core staff, those full-time team members to constantly pick up and work above their FTE is not sustainable.

Rose (17:58):

Such great observations that you're making there. One of the things that you talked about in the blog was Brian, was your experience with equipment and how broken equipment, equipment that was frequently not working caused a lot of friction for staff, A lot of workarounds and can you talk more about this?

Brian (18:22):

Yeah. The thing that the piece of equipment that comes to mind the most is the computer on wheels or the workstation on wheels. I was at a conference several years ago in the vendor room and a gentleman came to me and said, Hey, this is, come look at this. This is the newest workstation on wheels that's 70 pounds and the rest of 'em are 150 pounds. And I thought then who wants to be connected to a 70 pound piece of equipment you have to take with you? Nurses have to be mobile and flexible and able to react and that's not the way to go. And then I lived that firsthand. So at this particular hospital there were some newer model computers on wheels and some older ones and the newer ones were definitely the preference. So staff would come in early for their shift, write their name on a post-it note and the shift and they would claim the computers on wheels and some of 'em would claim it for the whole weekend, Brian Friday through Sunday night shift.

(19:23):

And I thought, wow, that's their priority. They're coming in early to get the better workstation on wheels and that's not good. That shouldn't be the focus. And then barcode bed administration 100% is leads to safer outcomes. But when you have the scanner on a cord, it's not wireless that not does not hear, especially when you have semi-private rooms. And in this case, this hospital did have semi-private rooms. So if I had the window patient at night, it's hard to push that past the first patient's foot of the bed without waking them up and making a lot of noise and then getting over there to scan and sometimes it just wasn't worth it. It was so hard to do that. And if you had a patient with a large piece of equipment or you have the sequential compression devices at the foot of the bed, it's really hard to get in there to do this and we can't make nurses jobs harder for them.

Rose (20:22):

Yeah. That's a really good segue into my next question, which does involve passing medications. Because you mentioned in the blog that passing medications has become really a logistical nightmare and there's probably a lot of leaders out there that may be watching this that maybe have not themselves passed medications in quite a long. So explain to us what has changed over time that's making this more difficult and what could we do to make the whole process of passing medications easier for our staff?

Brian (21:06):

Great question. What comes to mind? Again, I was on a med-surg floor. I typically had a six patient ratio, six patients. I would get report from three or four different nurses. So that takes a long time in itself. So I started the shift automatically kind of feeling behind the eight ball. And then meds are scheduled almost hourly. You have like 8:00 PM 9:00 PM 10:00 PM and then midnight meds. That's not easy. And the hospital policy is usually given an hour early or an hour later. But if I've got six patients with hourly meds in that three hour time block, you can't round on all your patients, you can't do three rounds on six patients. You just can't have to be able to bundle care. So I would, which meant the people at the first whatever patient I would see first, which was inevitably the sickest one, right?

(22:00):

They were going to get nine o'clock meds early because by the time I got to my sixth patient, they were usually getting their eight o'clock meds late. And that was just the only way I could be efficient in this process. The other thing is insulin. So anytime I would, every patient seemed to be diabetic and it insulin coverage. So I rarely had a patient care tech. Sometimes we did, sometimes we didn't. And when we didn't, we did total care and I would be responsible for those blood sugars and I always wanted to be sure to get those. So I would go and get the blood sugars even before vital signs.

(22:41):

Then I would go to give insulin on the sliding scale and you have to have a double check. I can never find a nurse to double check for me. So I would be in the med room, I'm pulling drawing up the insulin and then I'm standing there with a foot out the med room yelling for a nurse to come double check with me. And then the Pyxis would time out, had to log back in. And it just made it so very efficient. And again, on a MedSurg floor with six patients, there might only be four or five nurses on that night and everybody's in their rooms and scattered and giving meds took a very long time getting blood sugars, getting insulin sign off also took a very long time. So to your question, what could we do differently? I think nursing leaders can work with pharmacy. You have to be able to bundle some meds. The hourly, whether it's a stat med that's ordered or if it's a routine med, they're going to be given bundled. So we might as well do some double checks and put some policies that support that practice because you have nurses who are working outside of policy physically because they to can't meet that two hour window sometimes if they have a very heavy patient workload, patient load, sorry.

Rose (23:50):

So it's interesting Brian, that you talk about the double check with the insulin and other drugs as well. There are a lot of systems now that are implementing virtual nursing and that is one of the responsibilities of the virtual nurse is to zoom in with the nurse that's in the room to be a second set of eyes and to document that the double checked. Is that something that you see as being would've been valuable and that unit you were on?

Brian (24:22):

Oh, 100%. And virtual nursing is kind of part of my purview and scope right now. So if you have a camera and you should, that has wide angle zoom and tilt to be able to zoom in to the point where you can see the unit of insulin and most cameras can makes a big difference because that double check is in the room with you. Now, some people have to measure this in the med room and they can't do this in the patient room. If that's one, a virtual nurse may not be the avenue or it may be if you have a camera in the room in the med room, I mean to have that nurse do that double check, it will save a lot of time two or three times a day charge nurses are hit or miss sometimes, especially nowadays, they have full patient workloads themselves. So you can't always depend on a charge nurse. And I love that you asked the question, this is an opportunity to leverage some of these emerging technologies to efficiently solve problems today.

Rose (25:18):

Really think about that. Another thing that you talked about in the blog, Brian, was bedside shift report, which is of course considered to be an absolute best practice. Yet you discuss how this really has led to many nurses being unable to leave on time. How could this be done differently or what recommendations would you have as a result of being out there doing bedside shift report and really looking at what actually happens during that report?

Brian (25:52):

Yeah, this may be a little more controversial because CNO has bedside and says that practice also in the CO suite, we're looking at incremental overtime. These are dollars that we think we can get savings. We don't want nurses missing lunch. We should be able to get your lunch, deserve a break in 12 hours. Unit leader should be focusing on that, but also for incremental overtime, it's the time over shift. Nurses are staying over to chart to document and to give report coming from an ICU background bedside shift report 100% we're checking lines, we're checking drips, we're checking connections to the patient, we're looking at dressings. All those things should still be done. But my perception really changed on the MedSurg floor. I had a lot of patients who would come in. An example I would use would be like lower leg cellulitis, maybe a spider bite or a cut or something.

(26:53):

I don't know that we need unless there's a dressing. If it's a new patient with a fresh wound, then maybe we want to go in and look at it together, but we don't need to go there and you don't need to tell me about lung sounds and the neuro assessment for this patient. It's a healthy, otherwise healthy patient who came in with lower leg cellulitis. Were given antibiotics. I don't need to know much more than that. I can get it from the chart if their family dynamics, I want you to tell me that. But going to the bedside is very time consuming. And what's even more time consuming is if I'm waiting to get report from four different nurses and we all have five or six or seven patients, I took seven patients, three different on three different occasions. That's a lot. And you cannot do that in 30 minutes.

(27:37):

You just can't. And I spent a lot of time, I would get report on two patients and I would sit there for 10 or 12 minutes waiting for another nurse to become free. And during that time I'm looking in the chart and I pretty much had a good idea of what's going on. There is an electronic health record out there that uses an avatar for lines, tubes and drains. That's a great visual of wounds and where everything is. And if that's up to date, I can get a really good picture of what's happening with that patient right there. And again, on med-surg, it's usually an isolated reason why they're there. If they're going septic or something, it may take more of a conversation, but I think there is an opportunity there to treat it more like an emergency department to have fast efficient handoff with the problem at hand. Again, if there's pertinent data, you have to share that. But there's so much in the electronic health record on med-surg specifically. We could be much more efficient at shift change.

Rose (28:33):

Such a great point because nurses now report that they're spending quite lengthy time during the shift on documentation. Do you have any recommendations about ways to streamline the documentation?

Brian (28:50):

We should only be charting what is absolutely necessary. There's a lot of screening tools and a lot of that may come from regulatory, but nurses are documenting more than is needed. Another aha I had was especially on med-surg is charting within defined limits and then having clarity on what that is. If every cell in the electronic health record drops down for a body system, respiratory, cardiac or anything, nurses feel obligated to put something in that cell even when they don't have to. And it's even worse, putting something incorrect is worse than not putting anything. So don't give them that opportunity. So really focusing on what is essential for this patient that can tell the story for other nurses and for all the care team to log in and have a picture of an idea of what's going on. But we document a lot of stuff, especially in this patient population that we don't need to. And some people just used it within defined limits. And actually this hospital did, but it still dropped down every box. And nobody wants to save with a bunch of empty blank space because they feel obligated to put something there. And especially if the nurse the shift before did, and then we're just copying forward sometimes when it's inappropriate.

Rose (30:13):

So Brian, you talked about, you've talked a lot about the activity that happened on this unit and one of the things that I think many nurses are saying today is that they really are not getting any time for breaks. What was your experience with breaks?

Brian (30:34):

Yeah, didn't get much of a break either. Back early in my career, we had kind of battle buddies. Rose and I worked together and I'm going to break you and you're going to break me. This particular unit was largely travel nurses and there wasn't a process for that. It was just when you could get away to go to lunch, yell or partner, grab somebody, Hey, will you watch my patients going on? And then you would try to sneak away, but you weren't putting the Cisco phone or the iPhone, you weren't putting that down. You were still kind of on call.

(31:12):

So there wasn't a good solution for that. It was better earlier in my career when you had that assigned, that buddy assigned to make sure you could get breaks. But in this particular hospital, and again, this was the tail end of the pandemic things, we were in a weird spot in healthcare. There wasn't for that. I appreciated the unit. Oftentimes they would say, we're going to order food. Everybody put your order in. And somebody would do that. And when you could sneak away to grab something to eat, you could. But nurses do need a break, an uninterrupted break, 12 hours is a very long time.

Rose (31:47):

For sure. And so this is kind of a wrap up question, Brian, that I really would like you to kind of address. And that is that I think you chose to do this on a medical surgical unit and med-surg units, as you know Brian, are probably the most problematic units that we have in healthcare in the United States today. It's hard to recruit for these units. It's hard to retain on these units. These are very busy with the patient volumes that we're seeing right now. What lessons did you learn on this medical surgical unit as a staff nurse that inform your leadership today? And more importantly, many chief nursing officers out there are really thinking about redesigning care on med surg. And if they're thinking about that, what should they be thinking about doing differently?

Brian (32:46):

Well, this probably won't surprise anybody to say this, but med-surg patients are not the traditional med-surg patients. Patients are very sick today. Everybody has multiple comorbidities. So these patients are sick. And I actually, I completed this assignment when I didn't have the initial intention to do that. And part of it was the team that I became used to working with great people, the culture of the team was very much of comradery. But med-surg is very underrated. It is key. And maybe because people want to specialize, but med-surg is a specialty really in itself. And you see everything, every part of the body. New technologies are coming and this is the unit that I think they should get a lot of the attention, a lot of focus. So we need to encourage people to go one into the profession and then into MedSurg and then to stay in MedSurg and really thrive. This is where new models of care I think will evolve the quickest. So we'll see the pendulum swing and you'll be at the forefront of a lot of the technology and innovations coming down the line.

Rose (33:55):

So Brian, you kind of closed the gap for yourself in terms of really understanding what's going on out there in the work environments. But for maybe CNOs that can't or don't really want to take a travel assignment like you did to go out there and really look at the differences, what recommendations would you have for them to close the gap between maybe their past experience and really what's happening in the contemporary workplace?

Brian (34:31):

Yeah, and that's interesting. I don't recommend everybody go take a travel assignment for one. It takes a lot of time. It is temporary, and especially if they're a sitting CNO, that needs to be their focus. But physicians often get into leadership roles and keep up with their specialty. They'll still practice as an anesthesiologist or hospitalist occasionally. I would love to see that change as people get into the initial stages of leadership. Don't lose those skills. And if you've already been a CNO and you're very removed from the bedside, continue to round and have leader rounding, it's okay to put scrubs on. You don't have to have executive rounding. Showing some humility would be great. And I very much appreciated by those early careerists, those nurses coming into it that, Hey, I know what you're going through. I'm here to help. I had mentioned earlier in our conversation an initiative we did called Moments of Gratitude, which was the leadership c-suite.

(35:31):

We actually ordered jerseys. We were scrub bottoms with a jersey because we were trying to focus on team. And we would schedule four hour blocks on a unit and we would go there and just task and help and ask questions and learn, pulling linens, pulling trash, cleaning out the break room refrigerator. We always got a lot of praise for doing that. And it is a good use of your time because you're trying to build culture and everybody has a game plan for retention and this is a big part of it. And then when you have those town halls, it's not me versus you, it's, Hey, we're all on this together. I'm here to help you. And it offers a lot more transparency and authenticity.

Rose (36:14):

Well, I want to thank you, Brian. I want to thank you first of all, not only doing this, but I really want to thank you also for sharing your experience because I learned a lot when you and I sat down and we wrote that original blog, and I think I've learned a lot today as well. And Erica, I'm going to turn it back over to you.

Erica (36:34):

Well, thank you both so much for leading such an informative discussion on really the reality that Med-surg nurses and all clinicians are facing today. And we also want to thank the works platform for sponsoring today's webinar and bringing Brian and Rose together as forward-Thinking, clinical leaders really creating true change in the industry. And we also ask that you check out the resources section you should see on your screen to learn more about how works is helping health systems increase fill rates, increase nurse retention, and decrease premium labor spend. Thank you all so much for joining us today, and we hope you have a wonderful afternoon.

Description

Disorganized workflows. Poor communication. Outdated and cumbersome equipment. Burdensome and unnecessary policies. These are just a few challenges that nurses encounter on a daily basis — and that nursing leaders are often unaware of, leading to low morale and increased turnover.

While many chief nursing officers schedule clinical rounding to stay in touch with staff nurses, unit leaders often heavily curate their CNOs' experiences, meaning they might not be getting the full picture. Knowing this, one CNO took a 13-week travel assignment to gain insights into what nurses are really up against today. In this live webinar, leaders will discuss what the CNO found and what hospital leaders can learn from the experience.

You'll learn:

  • What the day-to-day is like for nurses today
  • Factors that contribute to nurse burnout and dissatisfaction
  • How to address nurses' biggest pain points

Transcript

Erica (00:00):

Welcome everyone to today's webinar, What a Chief Nursing Officer Learned by Going Undercover. On behalf of Becker's Healthcare, I'm Erica Carbajal and thank you all so much for joining us. We also want to thank works the healthcare industry's leading flexible workforce platform for bringing us together for this conversation today. Before we start off, I've got a few just quick backend notes to walk through so you can go ahead and submit any questions you see throughout the webinar by typing them into the q and a box. You should see on the right side of your screen the session is also being recorded so it will be available after the event. If you want to go back and reference any of the information, you will be able to do so using the same login information you use to log in today to access that recording once it's available. And if at any time you're having any technology issues or trouble with audio, please just try refreshing your browser and you can also type in any technical questions into the q and a box and we're here to help on the backend with those. With that, we're so thrilled to welcome today's speakers. First we have Brian Wyrick, chief nursing leader of Banner Health and Rose Sherman, professor emeritus at Florida Atlantic University and editor in chief of nurse leader Brian and Rose. Thanks so much.

Rose (01:19):

Thanks for having us.

Brian (01:21):

Yeah, thank you.

Erica (01:23):

Well, Brian, I know in between executive positions you decided to take a 13 week travel assignment on a medical surgical unit outside your health system and know what you learned, surprised you change your perspective and will inform your work in the future. So I know you and Rose are going to get to talking about that, but before we get started here, Brian, if you could just speak to help us understand what prompted you to take a clinic day one a step further and commit to that MedSurg travel assignment.

Brian (01:54):

Yeah, thank you Erica. This was a decision I thought about for a long time and it was not intentional to lead to where we are now, but I had been a chief nursing officer or CNO I guess going on seven years at two different health systems. And I've always seen myself as a player's coach, a very visible leader, rounding frequently, all shifts, even doing an initiative we did called Moments of Gratitude, which would be like four hour blocks on a unit really diving in, helping pull linens, empty trash, clean break rooms, more than just executive leader rounding. I always got a really good ROI for that. It was in 2022 that I was promoted into a system nursing role. This was a corporate role. Banner's a very large health system, so I had an office at corporate, but this was the tail end of the pandemic.

(02:50):

We were largely remote at the time and I was really nervous about losing that connection to the bedside staff, the daily operations. I think of myself as a very strategic thinker. I was excited about the opportunity to focus on emerging technologies, new models of care, but I needed to stay clinically relevant. And also when you're focusing on new technologies and new models of care, I wanted to test my assumptions. The worst thing you can do is create tools to solve problems that aren't really problems or that team members don't need. I thought about taking a PRN job, but you have to orient on day shift and go through that. And really the path of least resistance was to be a traveler that you could start minimal orientation. And I thought, okay, I'm going to do this route. I don't know that I ever intended to finish a 13 week assignment.

(03:41):

I'm an ICU nurse by background. I didn't think I could go into an ICU. I have kept my BLS and ACLS up, but I'm so far removed from the bedside. I thought, hey, an ICU might not be safe. My ego told me I can go to med-surg, the basic skills will come back to me. I've got really good time management, I should be able to go there and cruise. So that's how I chose a med-surg assignment and I chose a competitor in town. I didn't know if I could do this to be honest with you. And if I decided to do shifts at my hospital and take five and six patient workload, what if I couldn't do it? What if I had an adverse event or a med error or what if I just couldn't keep up with the work and then left? What message would that send to the staff? So I decided to do it at a competitor in case I couldn't finish or anything like that. That wasn't the case and I learned a ton through the process.

Erica (04:39):

Yeah, fascinating to hear about all that background and I think such a timely session and discussion, especially as we hear about continue retention, turnover rates in med-surg units. So what a way to get a real feel for what's really happening. Rose and Brian, I'll go ahead and turn it over to you now to share more.

Rose (04:58):

Well, thank you Erica and Brian, really excited to talk with you about this because when we originally published this blog, you were incognito. I probably had tons of people ask me, who wrote that? Who was that about? And at that point in time I couldn't tell them. So what has led you to talk about this experience more publicly now?

Brian (05:24):

Yeah, initially I was incognito and we'll use that term because I was working at a competitive health system in town. I did not want them, my coworkers to know who I was because I didn't want to answer those questions and I didn't want to be treated any differently. I didn't want the questions to come, Hey Brian, what are the nursing pay rates at this hospital? What incentives are you using? Are you lowering traveler rates? What's your staffing ratio? I didn't want to answer any of those questions and I wasn't there to recruit nurses to recruit staff. This was truly for me to learn, connect dots, learn the electronic health record, test my assumptions and get a really good understanding of what the team members are going through. This was the back end of the pandemic. During it, a couple weeks in, I reached out to you Rose, I think of you as a true mentor and leader.

(06:19):

And I said, Hey, you're not going to believe what I'm doing and more importantly, you are not going to believe what I'm learning. And I was like four or five weeks in. So at the time I didn't want to put my name out there. I was still in the assignment. I didn't want to answer those questions, but when the assignment was over, I very, I reflected a lot on this, I learned a lot. My wife is also a nurse, so we talked about this and then I started talking about it publicly right away, getting in front of nursing students and nurses who are new nurses who are onboarding. I always get a good reception when I shared this story and really for one, I wouldn't ask you to do anything I wouldn't do as a nurse leader, but I would go and do take these assignments, right ups and downs for sure. But that's really, and then as it has continued to evolve and more people know, I did my travel assignment through Trusted Health was the agency I used and I told them who I was afterwards and they were very receptive of this and said, Hey, you need to tell more people. And they're the ones who kind of set this up today. As I said, I am telling people, I'm like, you're not telling enough people about this. So looking forward to the next hour with you.

Rose (07:28):

Yeah. Well I think a lot of, one of the responses that I got right away, Brian, was that was really gutsy to put himself in that position. And I think you've talked a little bit about why you did it. I guess I'm wondering what surprised you the most about taking this travel assignment? What are some of the unanticipated things that you did not expect?

Brian (07:55):

Well, I really wanted to focus on, again, testing my assumptions, new models of care, emerging technology, natural language processing, this AI ML takeover that we're in, do these work. That's what I really wanted to do. One of the things I learned the most though is a lot of our nurses are not having their basic needs met. And before you can build these levels of complex technologies without having that strong foundation, it's just not going to be successful. So those basic needs have to be met initially. That was one of my key takeaways at the conclusion of this.

Rose (08:33):

Well, I think in the blog you mentioned that you felt that there was a need for more positive recognition, and I think what really stood out to me was that you said as you looked at the communication that was coming in from the executive team in the medical center and you looked at it through the eyes of the staff as they were looking at it, you really felt like much of it seemed very punitive or negative. Can you talk more about that?

Brian (09:05):

Yeah. One of the things, and I was looking at this through a unique lens, one of the things where if the unit has a quality board, it has to be kept up to date by leadership. If it's not, it sends a very clear message of what is and isn't important. So if you've got data that's two months old, if you're monitoring falls or any hospital acquired infection, that really sends a strong message to the team. During my assignment, I had two positive feedbacks that really made me feel really, really good. And I was surprised at how I reacted to this one. About halfway through, I was asked if I would take externs. This health system had a really good extern program. These were students in their last year of nursing school. They could work as a patient care tech, but they could do more skills.

(09:55):

And it made me feel really good to be asked to take externs as a travel nurse. And then they asked me to take students and I thought, again, wow, that's the biggest compliment you could give me, asking me a traveler to do this. And I felt very good about that, getting that recognition, but I didn't need recognition. I've been a nurse for 18 years. I could have quit this travel assignment any day, but there was a lot of new graduates on the unit. I thought, if I'm feeling this good for positive recognition, they need this a hundred times what I'm getting because it's a tough environment. And as I'm looking at the communication that was coming out, a lot of it, I don't want to say punitive, but it was you collectively, this policy is changing or here's a reminder of this policy. We had a lot of continuous bladder irrigations on the unit, the five bags, you put it way outside the room, a lot of empty bags. And we got a lot of communication about people doing this wrong. And it really felt like we were just trying to live 12 hours at a time and provide good care to these patients. And this particular unit had a very heavy workload, six and seven patient ratios with multiple patients on continuous bladder irrigation that it made you run, it made you work really hard. And the communication was constantly, this is the policy, it's not being followed, do this or else. And that resonated with me.

Rose (11:26):

Well, just as a follow up to that, Brian, I think one of the things that a lot of executive leaders struggle with right now is just communication, how to communicate to staff what methods of communication are the most effective. Have you changed your communication at all as an impact of having done this

Brian (11:45):

Afterwards? And I guess kind of simultaneously, email's not the way to go. It does lead to paper trail, but I liked using live video updates with a selfie stick or with an iPhone on a stand, but doing a video update and then uploading those to a platform, whether it's like a private Facebook group or Yammer. And then through those you can monitor how many people have watched this. But you can get, if something changes today, I could get that out to a large group in an hour and it's my face, it's me talking. It's not an email that's buried in their inbox. That's probably the one big change I did during this time.

Rose (12:26):

Yeah, that was probably a great learning because many staff, they just don't have time to read all this communication and they are in cognitive overload, as you said in the blog, you were as well. And so one of the things that I hear managers and leaders talk about today, Brian, is that staff seem very transactional when they make these requests, when they're requested to work overtime or they themselves want scheduling changes that it all seems so transactional to the leaders. How did this experience maybe change your thinking about these exchanges that go on between leaders and staff asking one another to do things?

Brian (13:16):

This was one of my big aha moments because I've been in the C and o chair so many times when we're going into the weekend or to the end of the week and we're looking maybe a shift ahead, we're looking at night shift or tomorrow day shift and we're significantly short staffed. We're not going to be able to have appropriate and efficient daily operations. So here's where the pay incentives come out right now. What are the carrots we can dangle to get staff to come in? And as a CNO, it always felt like everybody's holding out until we give a bigger, we offer a bigger carrot and then we'll get people to sign up and Hey, we're trying to deliver patient care here. Why would you guys hold us hostage? And I get the dollar conversation and so forth. But that was always my perception until I lived it on the other side.

(14:12):

So this was maybe a Friday night at 8:00 PM I'm coming on to shift, I work night shift. Day shift is leaving and the day shift charge nurse says to the collective, Hey, we've got a lot of patients in the emergency department. We're going to fill up tonight and tomorrow morning we are going to be significantly short just with the volumes we already have. And if we have any call offs, we're going to be in trouble. Is anybody willing to pick up tomorrow? And I'm watching this play out in the immediate question is what incentives are being offered? And at this health system, they had a standard stipend per shift. I think it was like hundred dollars and they could use callback pay. And then they had double time. And it was very clear the nurses wanted double time. That was the desired incentive for them to work.

(15:03):

And the charge nurse said, no, this has been escalated to the house supervisor and the CNO and the responses we're not offering double. And the conversation among these nurses that I was watching, they all had a good reason. One of 'em said, it's eight o'clock at night, I would have to find childcare for essentially 13 hours tomorrow. And then to pay for childcare for 13 hours isn't worth coming in for that hourly rate. I would lose money and I lose an entire day with my infant. I was like, wow, that's a really good point. And then another one said, I just bought my daughter her first car. I have worked so many shifts, I just need a day off. I'm not going to work. There's no amount of money it's going to bring me in. I had met this goal and then another one said to those other two, if they do offer double bonus, don't put it on our group text because Mike, who I presume was her husband, will make me come in and I need a day off.

(16:03):

And I thought her and Mike probably have some financial goals, you know what I mean? And he's saying, go take advantage. And she's saying, I need a break. But none of the three of them were out to stick it to management. They had very real life instances that they were weighing to decide if they wanted to come in or not. And I watched that and they were all very sincere in their declining of picking up this shift. And it was all family related and very, very good reasons. And I had never seen that. And the c and o, whenever he or she got the report, nobody's picking up. I know the reaction they're going to have because they got to solve this, but it's not because they were out to get 'em.

Rose (16:46):

So just as a follow up to that, Brian, is there a better approach that A CNO could use other than what was used in that circumstance and maybe what you yourself have used in the past?

Brian (16:59):

Yeah, I think there are technologies coming out. I would lean on technology. You have to take the negotiation out of it for management and staff, I really go to think about the gig economy and a higher PRN pool. You have to have more nurses to tap into and you have to automate that. You can't have managers in their offices texting, blast texting all day in morning. And then in the afternoon when there's a new new incentive that's offered, bring in a platform or an application that leadership can put guardrails or triggers in that automates all of that, the communication, the incentives and let that work for you. That's what this new technology with machine learning is incredible. That's what makes me think we have to tap into that. Just begging core staff, those full-time team members to constantly pick up and work above their FTE is not sustainable.

Rose (17:58):

Such great observations that you're making there. One of the things that you talked about in the blog was Brian, was your experience with equipment and how broken equipment, equipment that was frequently not working caused a lot of friction for staff, A lot of workarounds and can you talk more about this?

Brian (18:22):

Yeah. The thing that the piece of equipment that comes to mind the most is the computer on wheels or the workstation on wheels. I was at a conference several years ago in the vendor room and a gentleman came to me and said, Hey, this is, come look at this. This is the newest workstation on wheels that's 70 pounds and the rest of 'em are 150 pounds. And I thought then who wants to be connected to a 70 pound piece of equipment you have to take with you? Nurses have to be mobile and flexible and able to react and that's not the way to go. And then I lived that firsthand. So at this particular hospital there were some newer model computers on wheels and some older ones and the newer ones were definitely the preference. So staff would come in early for their shift, write their name on a post-it note and the shift and they would claim the computers on wheels and some of 'em would claim it for the whole weekend, Brian Friday through Sunday night shift.

(19:23):

And I thought, wow, that's their priority. They're coming in early to get the better workstation on wheels and that's not good. That shouldn't be the focus. And then barcode bed administration 100% is leads to safer outcomes. But when you have the scanner on a cord, it's not wireless that not does not hear, especially when you have semi-private rooms. And in this case, this hospital did have semi-private rooms. So if I had the window patient at night, it's hard to push that past the first patient's foot of the bed without waking them up and making a lot of noise and then getting over there to scan and sometimes it just wasn't worth it. It was so hard to do that. And if you had a patient with a large piece of equipment or you have the sequential compression devices at the foot of the bed, it's really hard to get in there to do this and we can't make nurses jobs harder for them.

Rose (20:22):

Yeah. That's a really good segue into my next question, which does involve passing medications. Because you mentioned in the blog that passing medications has become really a logistical nightmare and there's probably a lot of leaders out there that may be watching this that maybe have not themselves passed medications in quite a long. So explain to us what has changed over time that's making this more difficult and what could we do to make the whole process of passing medications easier for our staff?

Brian (21:06):

Great question. What comes to mind? Again, I was on a med-surg floor. I typically had a six patient ratio, six patients. I would get report from three or four different nurses. So that takes a long time in itself. So I started the shift automatically kind of feeling behind the eight ball. And then meds are scheduled almost hourly. You have like 8:00 PM 9:00 PM 10:00 PM and then midnight meds. That's not easy. And the hospital policy is usually given an hour early or an hour later. But if I've got six patients with hourly meds in that three hour time block, you can't round on all your patients, you can't do three rounds on six patients. You just can't have to be able to bundle care. So I would, which meant the people at the first whatever patient I would see first, which was inevitably the sickest one, right?

(22:00):

They were going to get nine o'clock meds early because by the time I got to my sixth patient, they were usually getting their eight o'clock meds late. And that was just the only way I could be efficient in this process. The other thing is insulin. So anytime I would, every patient seemed to be diabetic and it insulin coverage. So I rarely had a patient care tech. Sometimes we did, sometimes we didn't. And when we didn't, we did total care and I would be responsible for those blood sugars and I always wanted to be sure to get those. So I would go and get the blood sugars even before vital signs.

(22:41):

Then I would go to give insulin on the sliding scale and you have to have a double check. I can never find a nurse to double check for me. So I would be in the med room, I'm pulling drawing up the insulin and then I'm standing there with a foot out the med room yelling for a nurse to come double check with me. And then the Pyxis would time out, had to log back in. And it just made it so very efficient. And again, on a MedSurg floor with six patients, there might only be four or five nurses on that night and everybody's in their rooms and scattered and giving meds took a very long time getting blood sugars, getting insulin sign off also took a very long time. So to your question, what could we do differently? I think nursing leaders can work with pharmacy. You have to be able to bundle some meds. The hourly, whether it's a stat med that's ordered or if it's a routine med, they're going to be given bundled. So we might as well do some double checks and put some policies that support that practice because you have nurses who are working outside of policy physically because they to can't meet that two hour window sometimes if they have a very heavy patient workload, patient load, sorry.

Rose (23:50):

So it's interesting Brian, that you talk about the double check with the insulin and other drugs as well. There are a lot of systems now that are implementing virtual nursing and that is one of the responsibilities of the virtual nurse is to zoom in with the nurse that's in the room to be a second set of eyes and to document that the double checked. Is that something that you see as being would've been valuable and that unit you were on?

Brian (24:22):

Oh, 100%. And virtual nursing is kind of part of my purview and scope right now. So if you have a camera and you should, that has wide angle zoom and tilt to be able to zoom in to the point where you can see the unit of insulin and most cameras can makes a big difference because that double check is in the room with you. Now, some people have to measure this in the med room and they can't do this in the patient room. If that's one, a virtual nurse may not be the avenue or it may be if you have a camera in the room in the med room, I mean to have that nurse do that double check, it will save a lot of time two or three times a day charge nurses are hit or miss sometimes, especially nowadays, they have full patient workloads themselves. So you can't always depend on a charge nurse. And I love that you asked the question, this is an opportunity to leverage some of these emerging technologies to efficiently solve problems today.

Rose (25:18):

Really think about that. Another thing that you talked about in the blog, Brian, was bedside shift report, which is of course considered to be an absolute best practice. Yet you discuss how this really has led to many nurses being unable to leave on time. How could this be done differently or what recommendations would you have as a result of being out there doing bedside shift report and really looking at what actually happens during that report?

Brian (25:52):

Yeah, this may be a little more controversial because CNO has bedside and says that practice also in the CO suite, we're looking at incremental overtime. These are dollars that we think we can get savings. We don't want nurses missing lunch. We should be able to get your lunch, deserve a break in 12 hours. Unit leader should be focusing on that, but also for incremental overtime, it's the time over shift. Nurses are staying over to chart to document and to give report coming from an ICU background bedside shift report 100% we're checking lines, we're checking drips, we're checking connections to the patient, we're looking at dressings. All those things should still be done. But my perception really changed on the MedSurg floor. I had a lot of patients who would come in. An example I would use would be like lower leg cellulitis, maybe a spider bite or a cut or something.

(26:53):

I don't know that we need unless there's a dressing. If it's a new patient with a fresh wound, then maybe we want to go in and look at it together, but we don't need to go there and you don't need to tell me about lung sounds and the neuro assessment for this patient. It's a healthy, otherwise healthy patient who came in with lower leg cellulitis. Were given antibiotics. I don't need to know much more than that. I can get it from the chart if their family dynamics, I want you to tell me that. But going to the bedside is very time consuming. And what's even more time consuming is if I'm waiting to get report from four different nurses and we all have five or six or seven patients, I took seven patients, three different on three different occasions. That's a lot. And you cannot do that in 30 minutes.

(27:37):

You just can't. And I spent a lot of time, I would get report on two patients and I would sit there for 10 or 12 minutes waiting for another nurse to become free. And during that time I'm looking in the chart and I pretty much had a good idea of what's going on. There is an electronic health record out there that uses an avatar for lines, tubes and drains. That's a great visual of wounds and where everything is. And if that's up to date, I can get a really good picture of what's happening with that patient right there. And again, on med-surg, it's usually an isolated reason why they're there. If they're going septic or something, it may take more of a conversation, but I think there is an opportunity there to treat it more like an emergency department to have fast efficient handoff with the problem at hand. Again, if there's pertinent data, you have to share that. But there's so much in the electronic health record on med-surg specifically. We could be much more efficient at shift change.

Rose (28:33):

Such a great point because nurses now report that they're spending quite lengthy time during the shift on documentation. Do you have any recommendations about ways to streamline the documentation?

Brian (28:50):

We should only be charting what is absolutely necessary. There's a lot of screening tools and a lot of that may come from regulatory, but nurses are documenting more than is needed. Another aha I had was especially on med-surg is charting within defined limits and then having clarity on what that is. If every cell in the electronic health record drops down for a body system, respiratory, cardiac or anything, nurses feel obligated to put something in that cell even when they don't have to. And it's even worse, putting something incorrect is worse than not putting anything. So don't give them that opportunity. So really focusing on what is essential for this patient that can tell the story for other nurses and for all the care team to log in and have a picture of an idea of what's going on. But we document a lot of stuff, especially in this patient population that we don't need to. And some people just used it within defined limits. And actually this hospital did, but it still dropped down every box. And nobody wants to save with a bunch of empty blank space because they feel obligated to put something there. And especially if the nurse the shift before did, and then we're just copying forward sometimes when it's inappropriate.

Rose (30:13):

So Brian, you talked about, you've talked a lot about the activity that happened on this unit and one of the things that I think many nurses are saying today is that they really are not getting any time for breaks. What was your experience with breaks?

Brian (30:34):

Yeah, didn't get much of a break either. Back early in my career, we had kind of battle buddies. Rose and I worked together and I'm going to break you and you're going to break me. This particular unit was largely travel nurses and there wasn't a process for that. It was just when you could get away to go to lunch, yell or partner, grab somebody, Hey, will you watch my patients going on? And then you would try to sneak away, but you weren't putting the Cisco phone or the iPhone, you weren't putting that down. You were still kind of on call.

(31:12):

So there wasn't a good solution for that. It was better earlier in my career when you had that assigned, that buddy assigned to make sure you could get breaks. But in this particular hospital, and again, this was the tail end of the pandemic things, we were in a weird spot in healthcare. There wasn't for that. I appreciated the unit. Oftentimes they would say, we're going to order food. Everybody put your order in. And somebody would do that. And when you could sneak away to grab something to eat, you could. But nurses do need a break, an uninterrupted break, 12 hours is a very long time.

Rose (31:47):

For sure. And so this is kind of a wrap up question, Brian, that I really would like you to kind of address. And that is that I think you chose to do this on a medical surgical unit and med-surg units, as you know Brian, are probably the most problematic units that we have in healthcare in the United States today. It's hard to recruit for these units. It's hard to retain on these units. These are very busy with the patient volumes that we're seeing right now. What lessons did you learn on this medical surgical unit as a staff nurse that inform your leadership today? And more importantly, many chief nursing officers out there are really thinking about redesigning care on med surg. And if they're thinking about that, what should they be thinking about doing differently?

Brian (32:46):

Well, this probably won't surprise anybody to say this, but med-surg patients are not the traditional med-surg patients. Patients are very sick today. Everybody has multiple comorbidities. So these patients are sick. And I actually, I completed this assignment when I didn't have the initial intention to do that. And part of it was the team that I became used to working with great people, the culture of the team was very much of comradery. But med-surg is very underrated. It is key. And maybe because people want to specialize, but med-surg is a specialty really in itself. And you see everything, every part of the body. New technologies are coming and this is the unit that I think they should get a lot of the attention, a lot of focus. So we need to encourage people to go one into the profession and then into MedSurg and then to stay in MedSurg and really thrive. This is where new models of care I think will evolve the quickest. So we'll see the pendulum swing and you'll be at the forefront of a lot of the technology and innovations coming down the line.

Rose (33:55):

So Brian, you kind of closed the gap for yourself in terms of really understanding what's going on out there in the work environments. But for maybe CNOs that can't or don't really want to take a travel assignment like you did to go out there and really look at the differences, what recommendations would you have for them to close the gap between maybe their past experience and really what's happening in the contemporary workplace?

Brian (34:31):

Yeah, and that's interesting. I don't recommend everybody go take a travel assignment for one. It takes a lot of time. It is temporary, and especially if they're a sitting CNO, that needs to be their focus. But physicians often get into leadership roles and keep up with their specialty. They'll still practice as an anesthesiologist or hospitalist occasionally. I would love to see that change as people get into the initial stages of leadership. Don't lose those skills. And if you've already been a CNO and you're very removed from the bedside, continue to round and have leader rounding, it's okay to put scrubs on. You don't have to have executive rounding. Showing some humility would be great. And I very much appreciated by those early careerists, those nurses coming into it that, Hey, I know what you're going through. I'm here to help. I had mentioned earlier in our conversation an initiative we did called Moments of Gratitude, which was the leadership c-suite.

(35:31):

We actually ordered jerseys. We were scrub bottoms with a jersey because we were trying to focus on team. And we would schedule four hour blocks on a unit and we would go there and just task and help and ask questions and learn, pulling linens, pulling trash, cleaning out the break room refrigerator. We always got a lot of praise for doing that. And it is a good use of your time because you're trying to build culture and everybody has a game plan for retention and this is a big part of it. And then when you have those town halls, it's not me versus you, it's, Hey, we're all on this together. I'm here to help you. And it offers a lot more transparency and authenticity.

Rose (36:14):

Well, I want to thank you, Brian. I want to thank you first of all, not only doing this, but I really want to thank you also for sharing your experience because I learned a lot when you and I sat down and we wrote that original blog, and I think I've learned a lot today as well. And Erica, I'm going to turn it back over to you.

Erica (36:34):

Well, thank you both so much for leading such an informative discussion on really the reality that Med-surg nurses and all clinicians are facing today. And we also want to thank the works platform for sponsoring today's webinar and bringing Brian and Rose together as forward-Thinking, clinical leaders really creating true change in the industry. And we also ask that you check out the resources section you should see on your screen to learn more about how works is helping health systems increase fill rates, increase nurse retention, and decrease premium labor spend. Thank you all so much for joining us today, and we hope you have a wonderful afternoon.

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